Complaint Investigation Report

The investigation revealed the following: in regards to the allegation "Staff handled resident in a rough manner resulting in injury.” It is alleged that on 05/18/2026 C1 became upset and was restrained by staff and hit C1’s head on the ground resulting in a bump on the right side of C1’s head. LPA interviewed the Administrator, and two (2) out of four (4) staff that denied the allegation stating that on 05/18/2026, C1 engaged in self-injurious behavior sustaining in a bloody nose. Administrator and two (2) out of four (4) staff also stated that on 05/18/2026 the staff engaged two (2) person CPI (Crisis Prevention Intervention) hold for four (4) minutes and released every thirty seconds which did not result in an injury. LPA interviewed an additional two (2) staff that denied the allegation stating that they have not handled C1 or any clients in a rough manner resulting in an injury and did not witness any staff handle C1 or any clients in a rough manner. The Administrator, and four (4) out of four (4) staff stated that C1 would engage in physical aggression and self-injurious behaviors where C1 goes to the floor and C1 harms C1’s own head. The Administrator and four (4) out of four (4) staff stated that when C1 engages in self-injurious behavior, staff conducts re-direct, de-escalate, and use blocking pads. The Administrator, and four (4) out of four (4) staff also stated that C1 engages in property damage, self-injurious behavior, and makes false allegations about staff. LPA obtained a SIR (Special Incident Report) indicating a incident that occurred on 05/18/2026 in which indicated C1 engaged in emotional outbursts and physical aggression toward staff in which staff intervened utilizing verbal redirection, approved blocking techniques, separation of peers to maintain safety, and a CPI hold was conducted by two (2) staff for approximately four (4) minutes and the hold was released every thirty seconds and C1 also engaged in self-injurious behavior and attempts to injure C1’s nose and face and makes false allegations about staff hurting C1. SIR also indicated that law enforcement arrived on 05/18/2026 and C1 was transported to the hospital on a 5150 hold on 05/18/2026. LPA attempted to interview C1 over the phone but LPA was unable to interview since C1 declined to be interviewed. LPA interviewed W1 that stated that C1 would engage in self-injurious behavior, physical aggression, and make allegations about staff. W1 also stated that the staff are properly trained in CPI procedures. LPA interviewed an additional three (3) clients that stated that they have not witnessed on 05/18/2026, C1 get restrained by staff and did not witness C1’s head hit the ground that caused a bump on C1’s head. However, one (1) of those clients stated witnessing C1 hitting a staff member and also stated the police took C1 away from the home on 05/18/2026. Those three (3) clients also stated that they have not been treated by staff in a rough manner and have not witnessed any other clients get treated by staff in a rough manner. LPA reviewed all documentation that C1 has a history of self-injurious behaviors, physical aggression, and false allegations about staff. [Continue to LIC9099-C]